Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, July 22, 2009

Tough Decisions

Sometimes our medical oncologists will us ask us to place Mediports on their patients ASAP so that chemotherapy can be started promptly. A lot of times my office will just add the patient onto the day's OR schedule and I'll meet the patient for the first time an hour or two prior to the procedure to discuss things. The other day I picked up the chart of a lady who needed a port and the first thing I noticed was that she was 92 years old. I must admit, my first thought was: what the hell are we doing here? She had metastatic breast cancer with lesions seen in her lungs and liver. I was all ready to march into the room and have an honest, heart to heart talk with the patient and the family about futile care and cost effectiveness etc etc.

But I composed myself. Every situation is different. I asked questions. I listened. Her breast cancer had been treated 15 years ago. This was an unusually late recurrence of disease. And the patient sure as hell didn't look like the typical 90 year old I know. She was robust and charming and full of zest. She was one of those old ladies who are always winking at you at the end of sentences. She kept telling me that I'd better not screw up the procedure. Her daughter sat next to her and smiled supportively.

I asked her if Dr X. had gone over the side effects of the proposed chemotherapy. She said yes. She understood it was not going to be easy. But she was ready to endure it. She had two grandchildren who hadn't gotten married yet. Anything to give her just a little more time. She winked again.

Dr X. is a respected oncologist in our community. She had been seeing him for over 10 years. He is an employed Cleveland Clinic doc, so he wasn't going to make any more money based on whether she chose chemotherapy or not. Assuredly this had been a difficult decision for him, recommending such an aggressive course. I was just meeting this woman for the first time. Who was I to presume to dictate to her what was reasonable? She had a long-standing relationship with a physician who undoubtedly was very honest with her about her options. The decision they made, it really wasn't any of my business. The port went in uneventfully.

These are the scenarios we see all the time in the real world practice of medicine. It isn't always cookbook-easy. But who do we want making these sorts of tough decisions: doctors/patients or some faceless bureaucracy in Washington DC that mindlessly follows an arbitrary algorith? Legitimate arguments can be made for both sides...

7 comments:

If you assume that doctors will act in the actual best interests of their patients, then doctors, of course.

The US has a very high number of ICU beds per capita, and an open ICU system (mostly). How much futile ICU care would there be if it was mandated that ICUs were closed? I don't know any intensivist who wants to look after a bunch of gomers with no chance of vent weaning. You can even incentivise it by inverse-exponentially curving the per diem payment to the intensivist for each patient; that way, intensivists are financially rewarded for short sharp ICU admissions to get a critically ill patient back on their feet, rather than to unnecessarily prolong life.

We just need immunity for refusing to provide futile care. The patient/family can try to find another doctor, but you should be able to say enough is enough.

At the risk of sounding cold-hearted, I'd go with the faceless actuary in Washington, DC. The money just isn't there.

I wouldn't go as far as Canada, where paying for care the government doesn't approve of is apparently ILLEGAL. I mean, if Granny or her family wants to pony up with cash, let them go for the chemo. But save the taxpayer's money for stuff that we will get our money's worth on.

@DKV: As an oncologist, I try to be very realistic about the chemotherapy that I offer. The faceless actuary can not take into account variables that a physician can. I once treated a 90 year old with metastatic cancer. At time of diagnosis, he managed a "little" garden (a 2 acre plot; he did ALL of the work). I offered dose modified single agent therapy. He responded wonderfully, and for two years continued to manage that garden. When his disease progressed through treatment and his performance status finally failed, he moved to a supportive care mode (i.e. hospice) and died a several months later at home.

You can argue this was an exceptional patient with an exceptional cancer. However, with the behavior of his cancer being a wild-card, I would also argue this very healthy very active 90 year old had a better chance from the beginning than a 55 year old with a 80 pack year smoking history, diabetes, renal insufficiency and vascular disease (s/p amputation of a few body parts) who presents with a stage III lung cancer. There seems to be no question that the 57 year old should be treated yet there are select 80 and 90 year olds who are going to do far better. Do we really think the actuaries are going to have the guts to tell the person who has a "6 pack" of co-morbidities but is quite young that he/she will not get treatment because they have one too many diseases? I don't have that trust.

This is going to be a very tough road and a very tough discussion. I worry about "age-ist" policies but as a society we can not afford to treat all to the bitter end (and it is not appropriate to do so).

I'd rather have a "faceless actuary" than a for-profit health insurance corporate bureaucrat.

But I'd much prefer, and certainly expect a combination of doctor/patient/family like we now have in that socialized Medicare system that everybody conservative must hate. (Because we're supposed to hate and fear socialized medicine, aren't we?)

At the risk of sounding cold-hearted, I'd go with the faceless actuary in Washington, DC. The money just isn't there.

Is that a fact? How 'bout if it was your mother? When we start deciding who lives and who dies, we become one step closer to Obama's vision of "do us a favor and die, will you?" Yes, you do, indeed, sound cold-hearted and people like you scare the crap out of me.

@ DKV: Which tabloid do you get your Canadian policy info from anyhow?

As a Canadian and a physician, I can tell you the government does not make the decisions.

Medical decisions are made by the physician. If a physician decides that something is warranted, the government pays. It doesn't call us up and try to convince us not to do it. It doesn't make the patient pay first and then fight about reimbursement. It pays.

If a given treatment is not available in an area, the government pays to send the patient to the treatment.

It is illegal to open a fee-for-service medical clinic in Canada, which pisses off a minority of people who see opportunity, but grab last Saturday's Toronto Star and check out the letters page if you want to see what Canadians really think of our system.

So in this case, there would have been a similar long discussion with the oncologist and the surgeon, and then they would have put in the port and carried on, and nobody's house would need remortgaging.

In the case of the 67-year old diabetic smoker with an A1C of 13 and anginal rest pain, and newly diagnosed metastatic to liver only colon ca, there would have been a long and difficult discussion and this gentleman would likely be gently told that he was unlikely to survive any intervention, sorry.

" He is an employed Cleveland Clinic doc, so he wasn't going to make any more money based on whether she chose chemotherapy or not."

My mom is being treated for stage 4 CUP but they think it is likely pancreatic cancer. She is 63. She recently stopped chemo because according the the CT scan her cancer did not. But as to my quotation, I did wonder if he initially recommended chemo because his private practice could make more money. This is despite the fact that he is a respected oncologist. It just seems like an doc could easily rationalize recommending treatments that are more in his interests then not. I can imagine the thought processes some must feel: "gee I took out all these loans so..." But that's probably just paranoia on my part. I am glad that she did have chemo however because one of her scans showed that her cancer did shrink some, buying her a little time.

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